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Department of Otolaryngology, Sinusitis is one of the most common diagnoses in Summary points
Head, and Neck Surgery, Aberdeen primary care. It causes substantial morbidity, often
Royal Infirmary, Aberdeen Rhinosinusitis is a common primary care condition
AB25 2ZN resulting in time off work, and is one of the common-
Most cases of acute rhinosinusitis resolve with
Correspondence to: est reasons why a general practitioner will prescribe symptomatic treatment with analgesics
kim.ah-see@nhs.net antibiotics.1
Chronic rhinosinusitis may, however, require referral to an
BMJ 2007:334:358-61 ear, nose, and throat specialist for possible endoscopic
doi: 10.1136/bmj.39092.679722.BE Sources and selection criteria sinus surgery if medical management fails
We searched Medline for recent papers (1996-2006) Patients with acute facial pain or headache but no other
using “sinusitis”, “rhinosinusitis”, “acute”, “chronic”, nasal symptoms are highly unlikely to have rhinosinusitis
“diagnosis”, and “management” as keywords. We also Urgent referral is required if complications of rhinosinusitis
searched the Cochrane Database of systematic reviews are suspected—such as orbital sepsis or intracranial sepsis
using the keywords “sinusitis” and “rhinosinusitis”. In
addition, we used a personal archive of references relat- five days or persistent symptoms beyond 10 days (but
ing to our clinical experience and updates written for less than 12 weeks) indicate non-viral rhinosinusitis,
Clinical Evidence. whereas viral disease lasts less than 10 days.4
The definition of chronic rhinosinusitis is nasal con-
Causes of sinusitis gestion or blockage lasting more than 12 weeks and
Sinusitis is generally triggered by a viral upper res- accompanied by one of the following three sets of
piratory tract infection, with only 2% of cases being symptoms: facial pain or pressure; discoloured nasal
complicated by bacterial sinusitis.2 About 90% of discharge or postnasal drip; or reduction or loss of
patients in the United States are estimated to receive smell (box 4).
an antibiotic from their general practitioner, yet in
most cases the condition resolves without antibio‑
tics, even if it is bacterial in origin.3 Most general Box 1 | Common causes of rhinosinusitis
practitioners rely on clinical findings to make the • Viral infection
diagnosis. Signs and symptoms of acute bacterial • Allergic and non-allergic rhinitis
sinusitis and those of a prolonged viral upper respi- • Anatomical variations
ratory tract infection are closely similar, resulting in Abnormality of the osteomeatal complex
frequent misclassification of viral cases as bacterial Septal deviation
sinusitis. Boxes 1 and 2 list common and rarer causes Concha bullosa
of rhinosinusitis. Hypertrophic middle turbinates
• Cigarette smoking
Clinical diagnosis and pathophysiology • Diabetes mellitus
The term sinusitis refers to inflammation of the • Swimming, diving, high altitude climbing
mucosal lining of the paranasal sinuses. However, as • Dental infections and procedures
sinusitis is invariably accompanied by inflammation
of the adjacent nasal mucosa, a more accurate term
Box 2 | Rarer causes of rhinosinusitis
is rhinosinusitis.
The European Academy of Allergology and Clinical • Cystic fibrosis
Immunology defines acute rhinosinusitis as, “Inflamma- • Neoplasia
tion of the nose and the paranasal sinuses characterised • Mechanical ventilation
by two or more of the following symptoms: blockage/ • Use of nasal tubes, such as nasogastric feeding tubes
congestion; discharge (anterior or postnasal drip); facial • Samter’s triad (aspirin sensitivity, rhinitis, asthma)
pain/pressure; reduction or loss of smell, lasting less • Sarcoidosis
than 12 weeks.” Additional symptoms—such as tooth- • Wegener’s granulomatosis
• Immune deficiency
ache, pain on stooping, and fever or malaise—help
• Sinus surgery
make the clinical diagnosis (box 3).4 The European
• Immotile cilia syndrome
Academy also suggests that worsening symptoms after
Chronic rhinosinusitis
Medical treatment options for chronic rhinosinusitis
should begin with topical nasal steroids along with
Osteomeatal complex
aggressive treatment of any underlying cause or
comorbid allergy. Oral steroids should be reserved
for refractory cases, particularly when underlying
allergy is present.7 If oral steroids are required, cau-
Fig 1 | Anatomy of the osteomeatal complex tion should be taken in at-risk groups, including
Box 5 | Bacteriology of acute and chronic rhinosinusitis ear, nose, and throat specialist. Additionally, prompt
Acute rhinosinusitis referral should be considered in cases where sinister or
Haemophilus influenzae, Streptococcus pneumoniae worrying features exist (box 6).
(rarely: anaerobes, Gram negative bacteria, Staphylococcus
aureus, Moraxella catarrhalis, Streptococcus pyogenes) What is the role of surgery for rhinosinusitis?
Chronic rhinosinusitis Surgery for rhinosinusitis should be considered
Anaerobes, Gram-negative bacteria, S aureus (rarely: only after maximal drug treatment has failed or
fungal) complications are suspected. Traditional open sinus
procedures for ���������������������������������
chronic rhinosinusitis have����������
been
Box 6 | Sinister features that should prompt referral to largely replaced by endoscopic techniques.19 With a
specialist better understanding of normal mucociliary clearance
• Unilateral signs (for example, unilateral polyp or mass) pathways and anatomy of the osteomeatal complex
• Bleeding (fig 1), endoscopic sinus surgery is now the mainstay
• Diplopia or proptosis of surgical treatment for ������������������������
chronic rhinosinusitis��.
• Maxillary paraesthesia Endoscopic sinus surgery entails restoring sinus
• Orbital swelling or erythema ventilation and drainage by careful removal of any
• Suspicion of intracranial or intraorbital complication soft tissue obstructing the natural drainage ostia in an
• Immunocompromised patient attempt to restore mucociliary function.20 After sur-
gery, intranasal steroids, saline douching, and nasal
patients with diabetes or active peptic ulceration. It toileting are important to help mucosal healing and
is often useful to give an intermediate dose of steroid avoid the formation of intranasal adhesions.
such as fluticasone nasules or betamethasone drops Surgery in acute rhinosinusitis is reserved for refrac-
to bridge the gap between oral and topical steroid tory or complicated cases and takes the form of sinus
spray preparations. Once symptoms have resolved, it lavage to drain pus and decompress the affected sinus.
is essential to maintain improvement with long term This can be performed endoscopically or via exter-
(>3 months) intranasal steroid treatment in the form nal trephination and is combined with perioperative
of an aqueous nasal spray.4 antibiotic cover and empirical use of saline douches
Oral antibiotics with anaerobic and Gram negative and sprays.
cover may be required, although the European Acad-
emy of Allergology and Clinical Immunology found What are the complications of rhinosinusitis?
limited evidence to support their use. They may be The complications of sinusitis are due largely to the
considered in patients who have failed to respond to proximity of the paranasal sinuses to the anterior cra-
initial intranasal steroid therapy or in those who have nial fossa and orbit, as well as the venous drainage of
severe symptoms with evidence of persistent nasal the mid-facial structures into the intracranial venous
sepsis. Symptom relief can be achieved in both acute sinuses.21
and chronic rhinosinusitis with the use of topical saline Up to 75% of orbital infections are attributable to
douches and sprays.4 sinonasal disease, with the ethmoid sinus the primary
Failure to respond to a three month period of ini- source.22 Orbital complications include orbital cellu‑
tial medical treatment should prompt referral to an litis (fig 2), subperiosteal abscess, and intraorbital
abscess, with the potential of blindness as a result of
additional educational resources venous compression around the optic nerve. Orbital
Resources for healthcare professionals complications occur via direct transmission through
• National Electronic Library for Health (www.nelh.nhs.uk/)—an online library the thin medial orbital wall (lamina papyracea) or
for NHS staff, patients and the public by haematogenous route to the neighbouring orbital
• Cochrane Library (www.thecochranelibrary.com)—contains high quality, structures.
independent evidence to inform healthcare decision making Frontal sinusitis may lead to osteomyelitis of the fron-
• BMJ Clinical Evidence (www.clinicalevidence.org)—resource for informing tal bone (Pott’s puffy tumour) and may also destroy the
treatment decisions and improving patient care
• Clinical Knowledge Summaries Service(www.prodigy.nhs.uk/)—up to
date source of clinical knowledge on common conditions for healthcare
professionals and patients
• GP notebook (www.gpnotebook.co.uk)—an online encyclopaedia of
medicine
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Rhinol 1992;6:37-43.
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Contributors: KWA-S participated in the editing and writing of the article,
Acta Otolarygol Suppl 1994;515:26-8.
and ASE did the literature search and contributed to the writing of the article. 14 Osguthorpe JD. Surgical outcomes in rhinosinusitis: what we know.
KWA-S is the guarantor. Otolaryngol Head Neck Surg 1999;120:451-3.
Competing interests: None declared. 15 Lane AP, Pine HS, Pillsbury HC III. Allergy testing and immunotherapy
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